APLASTIC ANEMIA
BYDR. A.SAI TEJA
INTRODUCTION
 Aplastic anemia is pancytopenia with bone marrow
hypocellularity.
 Men and women are affected with equal frequency.
 Age distribution is biphasic, with the major peak in the teens and
twenties and a second rise in older adults.
CAUSES
 INHERITED Fanconi's anemia
 Dyskeratosis congenita
 Shwachman-Diamond syndrome
 Reticular dysgenesis
 Amegakaryocytic thrombocytopenia
 Familial aplastic anemias
 Preleukemia (monosomy 7, etc.)
 Nonhematologic syndrome (Down, Dubowitz, Seckel)
CAUSES
 ACQUIRED Radiation
 Drugs and chemicals
 Viruses (non-A, non-B, non-C Hepatitis, EBV, Parvovirus B19, HIV-1)
 Immune diseases (Eosinophilic fasciitis, Thymoma,
Hyperimmunoglobulinemia, Graft-versus-host disease)
 Paroxysmal nocturnal hemoglobinuria, Pregnancy
 Idiopathic
RADIATION
 Marrow aplasia can be an acute sequale to radiation.
 Nuclear accidents power plant workers, employees of hospitals,
laboratories, and industry (food sterilization, metal radiography)
are susceptible to it.
 MDS and leukemia, but probably not aplastic anemia, are late
effects of radiation.
CHEMICALS
 Benzene
DRUGS Agents that regularly produce marrow depression as major toxicity in
commonly employed doses or normal exposures: Cytotoxic drugs
(alkylating agents, antimetabolites, antimitotics), some antibiotics.
 Agents that frequently but not inevitably produce marrow aplasia:
Benzene
 Agents associated with aplastic anemia but with a relatively low
probability: Chloramphenicol, Anticonvulsants etc.
INFECTIONS Hepatitis (non-A, non-B, non-C) is the most common
preceding infection.
 Infectious mononucleosis & parvo virus B19 in some cases
 Rarely other bacterial & viral infections
FANCONI’s ANEMIA Autosomal recessive disorder
 Chromosomes in Fanconi's anemia are peculiarly susceptible
to DNA cross-linking agent
 The most common, type A Fanconi's anemia, is due to a
mutation in FANCA.
 manifests as congenital developmental anomalies (short
stature, café au lait spots, and anomalies involving the
thumb, radius, and genitourinary tract), progressive
pancytopenia, and an increased risk of malignancy
DYSKERATOSIS CONGENITA X- linked, in some cases autosomal dominant
 mutations in genes of the telomere repair complex
 Characterized by Mucous membrane leukoplasia, dystrophic nails,
reticular hyperpigmentation, and the development of aplastic anemia
in childhood.
SHWACHMAN- DIAMOND SYNDRME compound heterozygous mutations in SBDS
 Marrow failure + Pancreatic insufficiency and malabsorption.
PATHOPHYSIOLOGY
 Bone marrow failure results from severe damage to the
hematopoietic cell compartment.
 There is replacement of the bone marrow by fat.
 An intrinsic stem cell defect exists for the constitutional aplastic
anemias
 Extrinsic damage to the marrow follows massive physical or
chemical insults such as high doses of radiation and toxic chemicals
 Immune mediators like Helper T cells, TNF, IFN-ϒ may be
involved in the pathogenesis.
CLINICAL PRESENTATION
 can appear seeming abruptly or have a more insidious onset.
 Bleeding is the most common early symptom. Easy bruising,
oozing from the gums, epistaxis, heavy menstrual flow, and sometimes
petechie (massive hemorrhage is unusual)
 Symptoms of anemia are also frequent, including lassitude, weakness,
shortness of breath, and a pounding sensation in the ears.
 Infection (due to leukopenia) is an unusual first symptom in aplastic
anemia.
CLINICAL EXAMINATION
 Petechiae and ecchymoses
 Pallor
 Retinal hemorrhage
 Look for other features associated with inherited causes
 Lymphadenopathy and splenomegaly are highly atypical of
aplastic anemia.
INVESTIGATIONS
BLOOD Smear shows large erythrocytes and a paucity of platelets and
granulocytes.
 Reticulocytes are absent or few.
BONE MARROW fatty biopsy specimen may be grossly pale
 Dilute smear
 “Dry tap" instead suggests fibrosis or myelophthisis
TREATMENT
 Hematopoietic growth factors
 Immunosuppression
 Stem cell transplantation
 Supplementation of blood products and supportive care
Hematopoietic growth factors Limited usefulness
Stem cell transplantation This is the best therapy for the younger patient with a fully
histocompatible sibling donor.
 For allogeneic transplant from fully matched siblings, long-term
survival rates for children are approximately 90%.
Immunosuppression As most of patients lack suitable donor, it is the treatment of choice
for them.
 ATG + Cyclosporine induces hematologic recovery in ≈ 60 % of
cases.
 Relapse is frequent, usually after withdrawl of cyclosporine.
 MDS may develop in 15% of treated patients.
 Increasing age and the severity of neutropenia are the most
important factors weighing in the decision between transplant and
immunosuppression in adults who have a matched family donor.
 Older patients do better with ATG and cyclosporine, whereas
transplant is preferred if granulocytopenia is profound.